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Difficulty: MediumPhysiological Adaptation

Three hours after a percutaneous liver biopsy, a client reports feeling mildly anxious and complains of a steady ache in the right upper quadrant. When collecting data, the practical nurse notes the client has cool, clammy skin. Current vital signs are heart rate 108 bpm, respirations 22/min, and blood pressure 102/66 mm Hg. Baseline vital signs prior to the procedure were heart rate 74 bpm, respirations 14/min, and blood pressure 134/80 mm Hg. What is the priority action for the practical nurse to take?

  1. A
    Administer the prescribed PRN oral analgesic to address the right upper quadrant pain.
  2. Notify the registered nurse immediately regarding the changes in vital signs and skin condition.Answer
  3. C
    Document the current findings in the electronic health record and reassess in one hour.
  4. D
    Assist the client into a left lateral recumbent position to promote comfort.

Answer

The priority action is to immediately notify the registered nurse regarding the changes in vital signs and skin condition, as these indicate early hypovolemic shock from internal bleeding.
The correct response prioritizes client safety by immediately escalating the situation to the registered nurse. The liver is a highly vascular organ, and bleeding is a major complication of a liver biopsy. The client is demonstrating classic signs of early hypovolemic shock: a significant increase in heart rate, a significant drop in blood pressure from their baseline, cool and clammy skin (due to peripheral vasoconstriction), and anxiety. These circulatory changes require immediate medical evaluation and intervention, placing this action above routine comfort measures or delayed reassessment.

Step-by-Step Solution

1
Compare current data to the pre-procedure baseline vital signs.
The heart rate has increased by 34 bpm, the respiratory rate increased by 8/min, and the systolic blood pressure decreased by 32 mm Hg.
Identifying significant deviations from baseline is critical for recognizing early postoperative complications.
2
Evaluate the clinical significance of the physical assessment findings.
The combination of right upper quadrant pain, tachycardia, relative hypotension, anxiety, and cool, clammy skin strongly suggests internal hemorrhage.
The liver is a highly vascular organ. Cool, clammy skin and tachycardia are sympathetic nervous system compensatory responses to decreased blood volume.
3
Determine the appropriate prioritization of nursing interventions.
Escalating the assessment findings to the RN or provider takes precedence over administering analgesics, documentation, or routine monitoring.
According to the ABC (Airway, Breathing, Circulation) framework, circulatory compromise is an emergency requiring immediate medical or RN-level intervention.

Key Concept

Recognition of Early Hypovolemic Shock and Prioritization
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Topics

Physiological Adaptation

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